Postpartum Contraception — Resumption of Ovulation and Methods of Birth Control

The selection of contraceptives is a personal choice, but the physician should provide information to the patient regarding the optimal contraception. The postpartum period is an ideal time to initiate contraception as women are continuing to follow up with their healthcare providers, and are likely to be more motivated to avoid the next pregnancy soon.

Overview

Contraception is the process of having children by choice and not by chance as guided by once socio-economic needs using various methods of contraception.

Postpartum contraception should consider factors like a resumption of ovulation, its effects on lactation, and the woman’s health. Ideally, all women requesting postpartum contraception should be advised not to wait until the resumption of their menstrual cycle, but instead, start their contraceptive use before resuming sexual activity. Physicians should also provide emergency contraception, if requested, to all women.

Reversible Postpartum Contraception

Natural family planning

Barrier method

Progestin-only oral contraceptive

Long-acting reversible contraceptive

Prolactin increasing cause ovulation diminishing

Reliability = 98%, if used correctly

Use of condoms and/or spermicides

Effective rate = 82%

Progestin-only or the mini-pill

Most reliable when taken at the same time everyday

LARC provide contraception for an extended period of time

There are several options

Resumption of Ovulation

Resumption of sexual activity is variable and dependent on various factors such as presence or absence of perineal trauma, mental status of the mother and the return of physiology to the pre-pregnant states. The exact time is thus variable.

Similarly, ovulation is unpredictable and can occur even before the onset of menstrual cycles in breastfeeding women which can fall anywhere between 27 days and 6 months after delivery. Therefore, the return of the menstrual cycle is not a good indicator of the appropriate time to initiate contraception but as a guide contraception is needed after 21 days postpartum as 60% of non-lactating women are fertile in this period.

Ovulation in women who are lactating or breastfeeding depends on the frequency and duration of breastfeeding, the maternal nutritional status and her body mass index (BMI). Ovulation in breastfeeding women is typically delayed due to the inhibition of hypothalamic gonadotropin-releasing hormone by prolactin.

The Center for Disease Control (CDC) updated their guidelines in 2011 which state that hormonal contraceptives should be avoided in the first three weeks postpartum due to the high risk of venous thromboembolism (VTE) in that period. Combined hormonal contraceptives can be prescribed between three to six weeks postpartum if there are no risk factors for VTE. In the presence of risk factors for VTE, e.g. a past history of VTE or a recent cesarean section delivery, hormonal contraceptives are contraindicated.

Postpartum Contraception Methods

Factors that determine the appropriate method of contraception include:

The timing.

Mothers preference.

Presence or absence of chronic medical conditions such as VTE, HTN or Malignancy.

The breastfeeding status of the mother i.e exclusive, token breastfeeding, or no breastfeeding at all.

The Lactational Amenorrhea Method (LAM)

This is an economical and temporary form of the contraceptive method in women who have amenorrhea and are breastfeeding at frequent, regular intervals and not expressing milk or bottle feeding. However, one should caution the mother that this method requires achievement of certain criteria for success which include:

The mother must carry out exclusive breastfeeding.

Breastfeeding must take place for a minimum of 8 times a day.

It can only be used up to six months after delivery.

One should not have resumed menses before initiating this method.

Hormonal contraception

Hormonal contraception methods are available in different formats such as pills, injection, implants, and intrauterine devices. Their use and preference is based on factors such as:

The imminent risk of VTE in the immediate post-partum period (up to 21 days) and the presence of VTE risk factors after 21 days contraindicates estrogen use.

Breastfeeding status of the mother as estrogen can reduce the quality and amount of breast milk.

They can ideally be started safely only after 42 weeks postpartum.

Non-lactating women can be offered hormonal contraception with estrogen four weeks postpartum, while breastfeeding women can be offered progesterone-only pill or medroxyprogesterone depot injection (DMPA; Depo-Provera) or levonorgestrel intrauterine system. DMPA should not be recommended for long-term use (more than two years) in older women as it is associated with a higher incidence of a decrease in bone density unless no other contraceptive alternatives are acceptable.

Barrier devices

Barrier devices, such as diaphragms and cervical caps, should ideally be fitted six weeks postpartum as pregnancy and delivery tend to alter the cervical and vaginal size and tone. Condoms and spermicides, on the other hand, can be offered in the immediate postpartum period. The use of contraceptive sponges should be postponed until at least 42 days postpartum to avoid toxic shock syndrome.

Intrauterine devices/systems

Both breastfeeding, as well as non-lactating women, can be offered intrauterine devices like the Copper T or intrauterine systems like the levonorgestrel (LNG-IUS). The Copper T is an ideal long-term contraceptive option and can be kept in situ for up to ten years.

If inserted in the immediate postpartum period, they are likely to be extruded and should ideally be inserted 30 to 42 days postpartum when the uterus has involuted completely. Three types of levonorgestrel systems are currently available. Each of these is effective for different durations ranging from three to five years.

Sterilization

Tubal sterilization is an effective and permanent contraceptive solution for women who have completed their childbearing. It should be offered with caution to women in unstable relationships, or young women, or those desirous of having children later.

This surgical procedure can ideally be performed in the immediate postpartum period as it is associated with lower failure rates compared to when it is performed later. When it is requested later, it can be done either laparoscopically or transcervical.

The woman should be informed that the tubes can take three to six months to close completely after the procedure so she should use another form of contraception until then. Confirmation about successful occlusion of the tubes requires a hysterosalpingogram.